72-Hour Antibiotic Time-Out Sample Template

Time-outs are a core practice in antibiotic stewardship, as they provide active assessment of an antibiotic prescription
that occurs 48–72 hours after first administration, taking into account laboratory culture and sensitivity testing results,
response to therapy, resident condition, and facility needs (e.g., outbreak situation). The following page includes a “72-
Hour Antibiotic Time-Out” form that may be customized to incorporate facility antibiotic time-out policies. The
information collected is meant to be used to reassess each resident’s antibiotic need, duration, selection, and de-
escalation potential. Completion of an antibiotic time-out is recorded in the resident record.

Electronic health record (EHR) systems can facilitate the time-out process by any of the following:
▪ Providing automated alerts for each patient on antibiotics, timed for 72 hours post-initial administration
▪ Generating a list of all patients in need of a 72-hour antibiotic review on a given day
▪ Documenting the completion of an antibiotic time-out in the resident health record for assessment of staff
compliance with time-out protocols

Major EHR systems have the capability to set alerts, generate user-defined reports, and include additional fields in
resident health records. Work with facility staff experienced with your EHR system or contact your EHR vendor if you
need assistance in setting up the above recommended management settings.

Minnesota Department of Health

Infectious Disease Epidemiology, Prevention and Control
PO Box 64975
St. Paul, MN 55164-0975
651-201-5414
health.stewardship@state.mn.us
www.health.state.mn.us

4/18/23
To obtain this information in a different format, call: 651-201-5414.

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 72-HOUR ANTIBIOTIC TIME-OUT SAMPLE TEMPLATE

72-Hour Antibiotic Time-Out

Resident name: _____________________________________ Date: ________________ Room #: _________________
Antibiotic(s) prescribed: ______________________________________________________________________________
Start date: ___________ Dose: ____________ Route: ____________ Duration: ___________ Stop date: ___________
Prescriber name: ____________________________________________________________________________________
Facility where antibiotic prescribed: ____________________________________________________________________
 ER  Medical office  Hospital  Other: ____________________________________________________________

Reason Antibiotic Prescribed Culture Date X-Ray Pathogen Signs & Symptoms
Skin | Wound | Cellulitis  Yes  No  Yes  No
Urinary Tract Infection (UTI)  Yes  No  Yes  No
Lung Respiratory Infection (LRI)  Yes  No  Yes  No
Other: ____________________  Yes  No  Yes  No

Antibiotic Appropriateness
Does resident meet Loeb criteria?  Yes  No
What are the risk factors/concerns?  PVD  Wound  Diabetes  Catheter  Penicillin allergy
 Other: _____________________________________________________
Does resident still have symptoms?  Yes  No
Are signs and symptoms improving?  Yes  No

Red Flags (select all that apply) Actions to Take (select all that apply)
 Antibiotic is ordered for more than 7 days  Inquire about lab diagnostic result if pending
 Antibiotic inconsistent with organism sensitivities  Remove catheter
 There is no stop date on antibiotic order  Update provider
 No labs are available  Notify nurse manager or facility supervisor
 IV route  Catheter  Penicillin allergy  No action needed
 Other: ______________________________________

To Be Completed by Attending Provider (Check all that apply. Describe any changes.)
 Antibiotic prescribed is appropriate
 Antibiotic should be discontinued
 Change antibiotic to: _______________________________________________________________________________
 Change antibiotic route to:  IV  PO
 Change duration of antibiotic to:  Days of therapy: __________________  End date: ________________
 Transmission-based precautions:  Standard  Contact  Droplet  Airborne  None
 Other: __________________________________________________________________________________________

Comments:

Provider’s Signature: _________________________________________________ Date: _____________________